Recommended Treatment for Inguinal Hernia
Surgical repair with mesh is the definitive treatment for inguinal hernia, with laparoscopic approaches (TEP or TAPP) offering advantages of reduced postoperative pain and faster recovery, while open Lichtenstein repair remains an excellent alternative when laparoscopic expertise is unavailable. 1, 2
Treatment Algorithm Based on Clinical Presentation
Uncomplicated/Elective Inguinal Hernias
Mesh repair is strongly recommended over tissue repair due to significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk. 3, 1
Surgical approach selection:
Laparoscopic repair (TEP or TAPP) is preferred when expertise is available, offering reduced postoperative pain, lower analgesic requirements, lower wound infection rates (P<0.018), and faster return to normal activities. 1, 2
Open Lichtenstein repair is the standard open technique when laparoscopic expertise is unavailable, patient has significant comorbidities, or local anesthesia is preferred. 1, 2
Both TEP and TAPP demonstrate comparable outcomes with low complication rates; TAPP may be easier in recurrent cases or when TEP proves technically difficult. 1
During TAPP, inspect the contralateral side after patient consent, as occult contralateral hernias are present in 11.2-50% of cases. 1, 2
Emergency/Incarcerated Hernias (Without Strangulation)
Immediate surgical intervention is mandatory to prevent progression to strangulation and bowel necrosis. 1, 4
For clean surgical fields (CDC Class I - no bowel compromise):
Prosthetic repair with synthetic mesh is strongly recommended (Grade 1A) for patients with intestinal incarceration but no signs of strangulation or need for bowel resection. 3, 1
Mesh repair is associated with lower recurrence rates without increased wound infection risk. 3
Laparoscopic approach is appropriate when there is no suspicion of bowel necrosis, allowing assessment of bowel viability throughout the procedure and potentially avoiding unnecessary bowel resection. 1, 5
Local anesthesia can be used for emergency inguinal hernia repair in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications. 1, 6
Strangulated Hernias (With Bowel Compromise)
Emergency surgical repair is mandatory as delayed diagnosis beyond 24 hours significantly increases mortality. 1, 7
Predictors of bowel strangulation include: SIRS criteria, contrast-enhanced CT findings, elevated lactate, serum creatinine phosphokinase (CPK), and D-dimer levels. 1, 7
For clean-contaminated surgical fields (CDC Class II - strangulation with/without bowel resection but no gross spillage):
Emergent prosthetic repair with synthetic mesh can be performed (Grade 1A recommendation) and is associated with significantly lower risk of recurrence regardless of hernia defect size. 3, 1
Open preperitoneal approach is preferable when strangulation is suspected or bowel resection may be needed. 1
General anesthesia is required when bowel gangrene is suspected or peritonitis is present. 1
Hernioscopy (laparoscopy through hernia sac) is recommended to assess bowel viability after spontaneous reduction of strangulated hernias, avoiding unnecessary laparotomy and decreasing hospital stay. 1, 5
Contaminated/Dirty Fields (CDC Class III-IV)
For small defects (<3 cm) with bowel necrosis or peritonitis:
Primary tissue repair is recommended; the Shouldice method is the best non-mesh repair technique. 1, 5
If direct suture is not feasible, biological mesh may be used. 1
If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are alternatives. 1
For unstable patients with severe sepsis or septic shock:
- Open management is recommended to prevent abdominal compartment syndrome. 1
Antibiotic Prophylaxis
Not recommended for average-risk patients in low-risk environments undergoing elective open surgery. 2
Never recommended for laparoscopic repair. 2
48-hour antimicrobial prophylaxis for intestinal strangulation and/or concurrent bowel resection (CDC classes II-III). 1
Full antimicrobial therapy for patients with peritonitis (CDC class IV). 1
Special Populations
Women with groin hernias: Laparoscopic repair is suggested to decrease chronic pain risk and avoid missing a femoral hernia. 2
Elderly patients: Emergency repair carries 10% mortality versus 0% for elective repair; all inguinal hernias should be repaired electively unless overwhelming contraindication exists. 8
Femoral hernias: Timely mesh repair by laparoscopic approach is suggested when expertise is available. 1
Critical Pitfalls to Avoid
Delaying repair of strangulated hernias leads to bowel necrosis, increased morbidity, and significantly higher mortality. 1, 7
Failing to assess contralateral side during TAPP misses occult hernias in up to 50% of cases. 1
Using plug repair techniques - the incidence of erosion is higher with plug versus flat mesh. 2
Watchful waiting in symptomatic patients - the majority will eventually require surgery; discuss surgical risks and watchful waiting strategy upfront. 2